Mumps Signs and Fever, headache, muscle aches, tiredness, hearing loss, loss of appetite, often followed by parotitis Symptoms (swelling of salivary glands). After puberty, can cause painful, swollen testicles (males) or ovaries (females). Other presentations: Aseptic meningitis, encephalitis, pancreatitis. Can be asymptomatic. Incubation Usually 16-18 days after exposure (range 12-25 days). Case Clinical definition: Acute parotitis or other salivary gland swelling lasting at least 2 days, or orchitis classification (testicular swelling) or oophoritis (swelling of ovary) unexplained by another more likely diagnosis. Confirmed case: meets clinical Probable case: meets clinical Suspected case: Parotitis, acute definition or other acute definition, AND positive test for salivary gland swelling, orchitis, illness characterized as aseptic serum anti-mumps IgM antibody, or oophoritis unexplained by meningitis, encephalitis, OR epi-linked to another probable another more likely diagnosis, hearing loss, or pancreatitis or confirmed case or linkage to a OR positive lab result with no AND confirmed by mumps community (defined by public mumps clinical symptoms (with PCR or culture. health) during a mumps outbreak. or without epi-link). Differential EBV, HHV-6, cytomegalovirus, parainfluenza virus 1 & 3, influenza A, coxsackie, tumors, immunologic diagnosis disease, salivary duct obstruction. Important for sporadic cases of parotitis with no high-risk exposure. Treatment Supportive therapy Laboratory Buccal and urine for RT-PCR: PHL performs this test; most commercial labs do not perform mumps PCR or culture. Mumps can be most reliably diagnosed by isolation of mumps virus or detection of mumps nucleic acid by PCR assay from buccal mucosa secretions. • Days 0-3 after parotitis onset (onset date is day 0): Collect buccal swab only. (IDEAL) • Days 4-10 after parotitis onset: Collect both buccal swab AND urine specimen. Place buccal swab in VTM, urine in sterile screw-capped container. Bag specimens separately. Serum for mumps IgM and IgG antibody detection: In general, serum can be sent commercially; request both IgM & IgG. Please note: Follow up to determine IgG results will be important for patients with unknown vaccination status, since a negative PCR cannot rule out mumps on a person previously exposed to mumps antigen, either by vaccination or previous infection. If unvaccinated: collect at first clinical encounter; If IgM negative within 5d of onset, collect another specimen to rule in/out. IgM reliably present >5d post-onset. If vaccinated: take acute specimen at 1st clinical encounter; IgM may not be detectable in vaccinated persons with mumps regardless of collection timing. Keep specimens cold & ship on ice within 24h; if >72h, freeze buccal & urine to -70°C, ship on dry ice. Public • Assess the likelihood of mumps: confirm compatible clinical symptoms, verify vaccination and travel Health history, and assess exposure risk such as contact with a person with mumps or linkage to a investigation community with a mumps outbreak. • Collect specimens as soon as mumps is suspected; arrange testing at PHL as appropriate. • Recommend immediate isolation of case (droplet precautions) for 5 days after parotitis onset. • Recommend appropriate infection control precautions to prevent additional exposures in healthcare facilities, schools, workplaces, and other public settings. • Identify close contacts of all suspected cases to assess their immune status. o Refer symptomatic contacts for evaluation by HCP and exclude from school, work, & child care. o Refer susceptible contacts and contacts w only 1 MMR dose or an unknown vaccination history for one dose of MMR vaccine. (All may return to school after a dose has been received) nd st o Recommend that exposed persons with 1 MMR receive a 2 dose (>28d after date of 1 dose). • Educate potentially exposed contacts to watch for symptoms for 12 days after the first exposure through 25 days after last exposure and seek immediate evaluation if symptoms occur. • If in health care setting, exclude exposed HCWs without documented immunity (2 MMRs) from the 12th day after the first exposure through the 25th day after last exposure. • Provide appropriate notifications to childcare centers, schools, and care facilities. Last Revised: September 2017 Washington State Department of Health Page 1 of 18 DOH # 420-065 Mumps 1. DISEASE REPORTING A. Purpose of Reporting and Surveillance 1. To assess the burden of mumps in Washington. 2. To identify cases in order to prevent further spread from cases by recommending appropriate preventive measures, including exclusion. 3. To educate potentially exposed individuals about signs and symptoms of disease, thereby facilitating early diagnosis and reducing the risk of further transmission. 4. To identify and vaccinate susceptible individuals. B. Legal Reporting Requirements 1. Health care providers: notifiable to local health jurisdiction within 24 hours. 2. Health care facilities: notifiable to local health jurisdiction within 24 hours. 3. Laboratories: Mumps virus, acute, by IgM positivity or PCR positivity notifiable to local health jurisdiction within 24 hours; specimen submission of isolate or clinical specimen associated with positive result is required* (2 business days). *In practice, submission of these specimens generally occurs only upon request rather than routinely. 4. Local health jurisdictions: notifiable to the Washington State Department of Health (DOH) Communicable Disease Epidemiology (CDE) within 7 days of case investigation completion or summary information required within 21 days. C. Local Health Jurisdiction Investigation Responsibilities 1. Begin routine case investigation within one working day. 2. Facilitate the transport of specimens to assist with the diagnosis of cases. 3. Recommend measures to prevent further spread from the case. 4. Identify and evaluate contacts; educate and recommend measures to prevent further spread from susceptible contacts. 5. Report all confirmed and probable cases as well as suspected cases with possible exposure to mumps to Communicable Disease Epidemiology (see Section 3). 6. Complete the mumps case report form (https://www.doh.wa.gov/Portals/1/Documents/5100/210-039-ReportForm-Mumps.pdf) and enter the data into the Washington Disease Reporting System (WDRS). 2. THE DISEASE AND ITS EPIDEMIOLOGY A. Etiologic Agent Mumps is caused by a single-stranded RNA paramyxovirus. Last Revised: September 2017 Washington State Department of Health Page 2 of 18 DOH # 420-065 Mumps Reporting and Surveillance Guidelines B. Description of Illness The classic symptom of mumps is parotitis (i.e., acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary glands), lasting at least two days, but may persist up to ten days or longer. Nonspecific prodromal symptoms may precede parotitis by several days, including low-grade fever which may last three to four days, myalgia, anorexia, malaise, and headache. However, mumps infection may present only with nonspecific or symptoms or may be a subclinical infection. Rates of classic parotitis among all age groups typically range from 31% to 65%, but in specific age groups can be as low as 9% or as high as 94% depending on the ages and immunization histories of the individuals in the group. Parotitis may be unilateral or bilateral, and any combination of single or multiple salivary glands may be affected. Parotitis tends to occur within the first 2 days and may first be noted as earache and tenderness on palpation of the angle of the jaw. Symptoms tend to decrease after one week and usually resolve after 10 days. Persons with history of potential exposure to mumps who have pain in their testes (males) or pelvic area (females) should be evaluated by their health care provider for potential orchitis (testicular inflammation) or oophoritis (ovarian inflammation not related to bacterial infection). Before the introduction of the mumps vaccine in the United States in 1967, 15% to 27% of infections were asymptomatic. The proportion of infections that are asymptomatic since the introduction of the vaccine has not been clearly determined. Persons with asymptomatic infection can transmit the virus. Mumps complications • Orchitis (testicular inflammation) is the most common complication of mumps in post-pubertal males. In the pre-vaccine era, orchitis was reported in 12 – 66% of males who get mumps after puberty. Orchitis usually occurs 1-2 weeks (average 4-8 days) after onset of parotitis. In mumps-associated orchitis, the onset is usually abrupt and includes swelling, tenderness, nausea, vomiting, and fever. Only one testicle is affected in 60-83% of male mumps cases with orchitis. Mumps orchitis rarely leads to sterility but it may contribute to subfertility. An estimated 1 in 10 men experience a decrease in their sperm count. However, this drop is very rarely large enough to cause infertility. • Oophritis. Historically, about one in 20 females who got mumps after puberty experienced swelling of the ovaries or oophritis (ovarian inflammation). In the 2006 and 2009–2010 U.S. mumps outbreaks, oophoritis rates were 1% or lower among post-pubertal females. The symptoms of oophoritis (lower abdominal pain, high temperature, feeling sick) usually pass once the underlying mumps infection is cleared. It may mimic appendicitis. There is no known relationship to impaired fertility. • Asceptic meningitis. In the pre-vaccine era, mumps accounted for approximately 10%